Sakura Histo-Tek VP1 User Manual

3. Certificate of Decontamination (Sample)
8-18
If you are returning any used medical device to Sakura Finetek Japan, please provide the following
information to help prevent contamination of other devices, etc., or living environment at our facility and the
workers who will be working on/handling your device. Fill out this Certificate of Decontamination and return
it with the device. If the device is not accompanied by this certificate, we will not unpack or repair the
instrument. If the returned medical device is deemed hazardous by Sakura Finetek, we will return the
device to you immediately. The cost of shipment will be borne by you.
 Date:
 Institution name:
 Equipment information
[Instrument name] [Model] [Serial number]
 Please answer the following questions regarding the usage status. (Circle where applicable. Use the Remarks field, if
necessary.)
Question
Answer
Remarks
1. Has this device been used at a hospital where legally
designated communicable diseases are treated?
Yes
No
2. Has this device been used in a ward where patients of legally
designated communicable diseases are staying?
Yes
No
3. Has this device been used in a room where pathological work
on infectious diseases is conducted?
Yes
No
4. Has this device been used in a room where testing of infectious
diseases is conducted?
Yes
No
5. Has this device been used in a room where articles used in
connection with infectious diseases are disposed of?
Yes
No
6. Has this device been used in a room where research on special
viruses is conducted?
Yes
No
7. Has this device been used in a room where articles used in
connection with special viruses are disposed of?
Yes
No
 Please answer questions regarding disinfection.
Whenever possible, please return the device after cleaning/disinfecting it using general disinfectant, primarily in
areas that likely came in contact with tissues, operators, etc.
Examples of general disinfectants: Disinfecting alcohol, 70% isopropanol, biguanide alcohol, benzalkonium chloride,
Chlorhexidine
1. Date of disinfection
2. Method of disinfection
 Remarks

Sakura Histo-Tek VP1 Specifications

General

Brand	Sakura
Model	Histo-Tek VP1
Category	Laboratory Equipment
Language	English